A cancer patient is removed from the transplant list at Cedars-Sinai for using medical marijuana and for failing to show up for a drug test. He is hoping the hospital will reconsider.

Norman Smith goes through medical records at his home in Playa Del Rey. "If… (Christina House / For the…)

Norman Smith, who has liver cancer, was placed on the transplant list at Cedars-Sinai Medical Center last year.

But early this year, doctors removed him because he was using medical marijuana and failed to show up for a drug test.

To get back on the list, Smith, 63, has to spend six months avoiding medical marijuana, submitting to random drug tests and receiving counseling. He is still undergoing chemotherapy and radiation for the cancer, which recently returned after being in remission. Smith has asked Cedars-Sinai to reconsider and reinstate him.

"It's frustrating," he said from his home in Playa del Rey. "I have inoperable cancer. If I don't get a transplant, the candle's lit and it's a short fuse."

Smith's case highlights a new twist on a long-running debate within the transplant community—should people whose use of drugs or alcohol may have contributed to liver problems be candidates for transplants? And if so, how long should they be clean before becoming eligible for a new organ?

With the ubiquitous presence of medical marijuana, doctors say patients like Smith who have prescriptions increasingly are showing up at transplant centers seeking new livers. Statistics on such requests aren't available, but experts agree the prescription medical marijuana cases are forcing doctors to revisit medical and ethical questions surrounding drug use and transplantation.

There is no standard on transplants and the use of medical marijuana or other drugs, according to the United Network for Organ Sharing, which manages organ transplantation for the U.S. Instead, transplant centers make their own decisions on which patients are the best candidates for new organs, meaning policies vary from center to center.

Livers are highly sought-after organs. More than 16,000 people are in line for livers nationwide and the average wait is about 300 days, according to the network.

"We have to do a prioritization, like you literally do on a battlefield — who can die and who can survive, because we don't have enough livers," said Dr. Goran Klintmalm, chief of the Baylor Regional Transplant Institute and an expert in liver transplantation. "As long as we have patients who die on the list waiting for organs … is it right to give [to] patients who have a history of drug use? You can discuss until the cows come home if it is social marijuana or medical marijuana."

Transplant doctors said one of the main concerns is compliance with a complicated regimen of post-transplant medications.

"If you are drunk or high or stoned, you are not going to take your medicine," said Dr. Jeffrey Crippin, former president of the American Society of Transplantation and medical director at Washington University in St. Louis.

Cedars-Sinai spokeswoman Sally Stewart said federal law prevented her from talking about Smith's case. But she said marijuana users can be exposed to a species of mold that can cause fatal disease among patients with compromised immune systems. They also run a risk of a fatal lung infection after transplantation, she said.

"We do not make a moral or ethical judgment about people who are smoking medical marijuana," she said. "Our concern is strictly for the health and safety of our patients."

At Cedars-Sinai, if patients who need a transplant initially test positive for marijuana, they can still be listed but must sign a statement agreeing not to use the drug. Then, if they fail a random drug test or don't show up for one, they are bumped from the list. "There have to be guidelines in order to give people the best chance at surviving a transplant," Stewart said.

UCLA Transplantation Services has an even stricter policy, requiring six months of sobriety before a patient can be listed. Dr. Douglas Farmer, a transplant surgeon and surgery professor at UCLA, said that drug and alcohol use is a "huge issue" and that patients on medical marijuana have also come to UCLA seeking transplants.

Farmer said, however, that many patients with medical marijuana prescriptions are not "legitimate" and transplant surgeons can't risk wasting a precious organ on someone who is going to continue abusing alcohol or drugs. "There are a significant number of people who come in for liver transplants who have a substance abuse history," he said.

Any delay in getting Smith a new liver could mean the "difference between life and death," said Joe Elford, an attorney with the medical marijuana advocacy group Americans for Safe Access, which is representing Smith and considering a lawsuit against the hospital.

Smith's oncologist, Dr. Steven A. Miles, an attending physician at Cedars, refilled the prescription for medical marijuana to manage his patient's pain. Miles, who is in private practice, agreed that by missing his drug test Smith raised concern about his patient's post-transplant compliance with medical instructions.